Mpower Mentoring Program Application

In a community-wide effort, LaunchNW is collaborating with over 20 local organizations to bring the Mpower Mentoring Program to our local high schools for year two!

Mpower is driven by collective impact. Designed alongside local school districts, businesses, nonprofit organizations, and universities, Mpower connects high school students with mentors and other wraparound supports to help them reach their post-high school education and career of choice. We invite you to invest in the future of our region by getting involved today.

Your Details

First Name

Middle Name

Last Name

Preferred Email

Email Type

Preferred Phone

Phone Type

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Birthdate

Employer (If Applicable)

Industry (If Applicable)

Your Industry

Gender Identity

MaleFemaleNonbinaryOtherPrefer not to say

Race/Ethnicity (check any that apply)

American Indian or Alaska Native	Asian	Black or African American
Hispanic or Latino	Middle Eastern or North African	Native Hawaiian or Pacific Islander
White	Multiple

Why are we asking this? We strive to have a team of mentors who reflect a representative body for our student mentees.

Preferred Volunteer Location(s) (check any that apply)

Central Spokane	North Spokane	Spokane Valley	Medical Lake
Cheney	Deer Park	Spangle	Any/No Preference

Were you referred by an individual or organization to participate in this program?

YesNo

Were you referred to the Mpower Mentoring Program by any of the following entities/individuals?

Please select the programs you would like to be involved with through the Mpower program.

1:1 Mentorship with a High School StudentThis mentorship is site-based and takes place at the high school during the school day 1-2 times per month.

Virtual Industry Advice DatabaseShare your career experiences and advice with students in a brief form. Takes 10 minutes to complete!

Informational InterviewShare your career expertise or advice with a student via an one-time in-person conversation.

Job ShadowingIndicate that you host job shadowing opportunities for high school students,

InternshipsIndicate that you host internships for high school students.

Mentorship Details

Availability for Mentorship Meetings

Monday Mornings (8 - 11am)	Monday Lunch (11am - 1pm)	Monday Afternoons (2:30 - 4pm)
Tuesday Mornings (8 - 11am)	Tuesday Lunch (11am - 1pm)	Tuesday Afternoons (2:30 - 4pm)
Wednesday Mornings (8 - 11am)	Wednesday Lunch (11am - 1pm)	Wednesday Afternoons (2:30 - 4pm)
Thursday Mornings (8 - 11am)	Thursday Lunch (11am - 1pm)	Thursday Afternoons (2:30 - 4pm)
Friday Mornings (8 - 11am)	Friday Lunch (11am - 1pm)	Friday Afternoons (2:30 - 4pm)

Notes regarding your availability: (optional)

When are you available to start mentoring?

Mentor Commitment

All mentor meetings will take place at the high school in which the student mentee is enrolled. Mentors are expected to meet with their student mentee 1-2 times per month for the duration of the academic year. Mentors will be expected to complete trainings and background checks prior to being matched with a student mentee.

Mentors will be assigned to one of our community partner organizations, who will coordinate meetings and provide other resources to ensure a successful mentor-student mentee partnership. To learn more about our community partners or if you have questions, please visit our website.

Please check below to confirm you agree to the terms of the mentor commitments listed above.

I confirm I have read and agree to the Mentor Commitment

Please proceed to page 2 after completing page 1 to complete our Background Check Authorization form.

Virtual Advice Database

How many years have you been in your current industry or career field?

Please enter a number in the field above.

What type of post-high school education is needed to pursue employment in your industry or career field? How many years of education?

What are your top three pieces of advice for a current high school student looking to enter your industry or career field?

What is the #1 misconception people have about your industry or career field?

Thank You!

Your information will be added to an internal database utilized by LaunchNW staff and our onsite Mpower coordinators within the following category(s). If we have student interest in your opportunity, we will reach out! Please contact LaunchNWinfo@innovia.org with any questions.

Internships

Job Shadowing

Informational Interview

Hidden Fields

Mpower Program ID

Mentor RT

Background Check Authorization Form

In order to perform an Mpower mentor background check, we must have your information and consent. If you have any questions about this process, please contact us at LaunchNWinfo@innovia.org.

List all other names you use or have used in the past, including married and maiden names, below. Separate each full name with a comma.

Your Address Information

Street Address

To search, please spell out all words in your address. Ex. "East" instead of "E"

City

County

State

Zip Code

Have you lived outside of Washington State any time in the last 5 years?

YesNo

Enter any previous physical address(es) of residence from the last 5 years

Notice and Authorization for Background Check

This is to inform you that LaunchNW may obtain information about you and/or your history related to potential criminal activity. The report from authorized sources may include, among other information, arrest, conviction, and final board disciplinary decisions. Information obtained by LaunchNW will be used only for the purposes of assessing your suitability to become a mentor. As provided by State Law (RCW 43.43.830) a disclosure statement must be made by an applicant, and background inquiries may be made of certain civil adjudication's, conviction records or crimes against persons and disciplinary board final decisions prior to appointment to positions which have unsupervised access to youth.

Such inquiries may be made to state and/or federal law enforcement agencies. Information obtained from the disclosure statement, or from the background inquiries, will not necessarily preclude appointment, but will be considered in determining the applicant's character, suitability, and competence to person in the position applied for and may result in a denial of appointment. The use of the record of these inquiries will be restricted to the decision on your application. Background check results will be made available to you within 10 days of the report being run.

If you wish to be considered for a mentor position, you must complete and sign this application and associated forms. Failure to do so will disqualify you for any mentor appointment. Please proceed below.

Disclosure and Consent to Release Information

I hereby authorize LaunchNW to procure a report on me, including a criminal background history, which I understand may include, among other information, arrest, conviction, and final board disciplinary decisions. If I become a mentor for LaunchNW, I authorize LaunchNW to repeat these investigations at any time for as long as I remain a mentor. I unconditionally release and hold harmless LaunchNW and its officers, directors, employees, and agents and any party furnishing information to them pursuant to this authorization from any liability, claims, charges, costs, or causes of action which I or my heirs, executors, or assigns may have as a result of the delivery, disclosure, non-disclosure, or omission of any information. Furthermore, I understand that LaunchNW holds the right to deny my participation in the program and, for confidentiality, is not required to disclose reasons for doing so. All parties agree that electronic/digital signatures are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility. A photocopy of this authorization may be accepted in lieu of the original.

I Agree

1. Have you ever been convicted of or pleaded "guilty" or "no contest" to a felony or misdemeanor as an adult or juvenile? Include deferred or probated adjudications as well as convictions that have been set aside

YesNo

2. Are you currently charged with (indictment or official criminal complaints by county or district county) a felony or misdemeanor?

YesNo

3. Have you been or are you currently being investigated for allegedly abusing, neglecting, or exploiting a child, an elderly person, or a person with disabilities?

YesNo

I declare the information provided on this statement is true and correct. I understand that any misrepresentation or omission of the information requested may result in my being barred from providing mentoring services with LaunchNW. I also agree to inform LaunchNW if I am named in complaints, indictments, or convictions of offenses as described in items 1&2, or if I am investigated for allegations as described in item 3 of this form. I consent to disclosure of any and all information, including confidential information, obtained from the above-referenced sources to LaunchNW in order to facilitate my volunteer service.

Yes

Full Name of Applicant (This functions as a digital signature)

Date Signed